DISTRIBUTED SIMULATION PROJECT Management of IV Fluids and Electrolytes

Joy Hills 2013 | RN, BSN, MSN (Cancer), SpecCertCR (Onc) Professional responsibilities

• Obtaining and adhering to organisational guidelines. (Including scope of practice guidelines)

• Have appropriate theory and skill preparation.

• Maintain individual accreditation in compliance with institutional or hospital guidelines. Objectives

Having completed this session you will be able to:

• Explain the uses of IV therapy, the role of red and white blood cells, platelets, plasma, and the six major electrolytes in intracellular and extracellular fluid • Understand osmolarity and the classification of solutions as hypertonic, isotonic and hypotonic • Understand the rationale for using/avoiding colloids, crystalloids, blood and blood products in different circumstances • Detect and respond appropriately to IV complications and the early manifestations of excesses and deficits of the six major electrolytes Definitions

• Intracellular – fluid within the cell • Extracellular – fluid outside the cell but in the interstitial space and in intravascular fluid • Interstitial – fluid between the cells – in the interspaces of a tissue – situated between the parts • Intravascular – within the vessel or vessels • Homeostasis – the tendency of biological systems to maintain relatively constant conditions in the internal environment, while continuously interacting with and adjusting to changes that originate within the system and outside the system Transport of fluids

• Diffusion – the movement of molecules/solutes through a semipermeable membrane from a high concentration to a low concentration • Osmosis – the one way passage of water through a semipermeable membrane from a low concentration of particles to a high concentration of particles • Filtration – fluid going through a filter under pressure or passage through a material that prevents passage of certain molecules • Active transport – electrolytes move from a low concentration to a high concentration by moving against the concentration gradient. ATP provides the energy needed to do this. IV therapy

• As many as 75% of patients admitted into hospital receive some type of IV therapy • 50%-70% of the average human is body fluids Distribution of fluid in the body is: 1/3 extracellular fluid • Interstitial fluid • Plasma or intravascular fluid • Transcellular fluid 2/3 intracellular fluid • Fluid within a cell • Red blood cells • Other cells Uses of IV therapy

• Establish or maintain fluid and/or electrolyte balance • Administer medication continuously or intermittently • Administer bolus medication • Administer fluid to maintain venous access in case of an emergency • Administer blood or blood products • Administer intravenous anaesthetics • Maintain or correct a patient’s nutritional status • Administer diagnostic reagents • Monitor haemodynamic functions • Correct acidosis or alkalosis IV therapy

Types of IV fluids

1. Crystalloids 2. Colloids 3. Blood and blood products Crystalloids

• Crystalloids are water with electrolytes that form a solution that can pass through semi permeable membranes • They are lost rapidly from the intravascular space into the interstitial space • They can remain in the extracellular compartment for about 45 minutes • Because of this, larger volumes than colloids are required for fluid resuscitation • Eventually, water from crystalloids diffuses through the intracellular fluid Crystalloids cont:

Hypertonic • A hypertonic solution draws fluid into the intravascular compartment from the cells and the interstitial compartments. Osmolarity is higher than serum osmolarity Hypotonic • A hypotonic solution shifts fluid out of the intravascular compartment, hydrating the cells and the interstitial compartments. Osmolarity is lower than serum osmolarity Isotonic • Because an isotonic solution stays in the intravascular space, it expands the intravascular compartment. Osmolarity is the same as serum osmolarity Common crystalloids

Solution Type Uses Nursing considerations

Dextrose 5% in water Isotonic Fluid loss Use cautiously in renal and cardiac patients (D5W) Dehydration Can cause fluid overload Hypernatraemia May cause hyperglycaemia or osmotic diuresis 0.9% Sodium Chloride Isotonic Shock Can lead to overload (Normal Saline-NaCl) Hyponatraemia Use with caution in patients with heart failure or oedema Blood transfusions Can cause hyponatraemia, hypernatraemia, hyperchloraemia Resuscitation or calorie depletion Fluid challenges Diabetic Keto Acidosis (DKA) Lactated Ringer’s Isotonic Dehydration Contains potassium, don’t use with renal failure patients (Hartmanns) Burns Don’t use with liver disease, can’t metabolise lactate Lower GI fluid loss Acute blood loss Hypovolaemia due to third spacing 0.45% Sodium Chloride Hypotonic Water replacement Use with caution (1/2 Normal Saline) DKA May cause cardiovascular collapse or increased intracranial Gastric fluid loss from NG or vomiting pressure Don’t use with liver disease, trauma or burns Dextrose 5% in ½ normal Hypertonic Later in DKA Use only when blood sugar falls below 250mg/dl saline

Dextrose 5% in normal Hypertonic Temporary treatment from shock if Contra-indicated for cardiac or renal patients saline plasma expanders aren’t available Addison’s crisis

Dextrose 10% in water Hypertonic Water replacement Monitor blood sugar levels Conditions where some nutrition with glucose is required Colloids

• Colloids contain solutes in the form of large proteins or other similar sized molecules • They cannot pass through the walls of capillaries and into cells • They remain in blood vessels longer and increase intravascular volume • They attract water from the cells into the blood vessels • But this is a short term benefit and • Prolonged movement can cause the cells to lose too much water and become dehydrated Common colloids

Colloid Action/use Nursing considerations Albumin Keeps fluids in vessels May cause anaphylaxis (a severe, often rapidly progressive allergic (Plasma protein) Maintains volume reaction that is potentially life threatening) – watch for/report wheeze, 4% or 20% Primarily used to replace protein persistent cough, difficulty breathing/talking, throat tightness, swelling and treat shock of the lips, eyes, tongue, face, loss of consciousness. May cause fluid overload and pulmonary oedema Dextran Shifts fluids into vessels May cause fluid overload and hypersensitivity (Polysaccharide) Vascular expansion Increased risk of bleeding 40 or 70 Prolongs haemodynamic Contraindicated in bleeding disorders, chronic heart failure and renal response when given with HES failure Hetastarch (HES) Shifts fluids into vessels May cause fluid overload and hypersensitivity (synthetic starch) Vascular expansion Increased risk of bleeding 6% or 10% Contraindicated in bleeding disorders, chronic heart failure and renal failure

Mannitol Oliguric diuresis May cause fluid overload (alcohol sugar) Reduces cerebral oedema May cause electrolyte imbalances 5% or 10% Eliminates toxins Cellular dehydration Extravasation may cause necrosis Blood and blood products

Plasma Plasma is the liquid part of the blood. It is often used to add volume to the blood system after a large loss of blood. Cryoprecipitate is a concentrated source of certain plasma proteins and is used to treat some bleeding problems Red blood cells Red Blood Cells carry oxygen from the lungs to other parts of the body and then carry carbon dioxide back to the lungs. Severe blood loss, either acute haemorrhagic or chronic blood loss, dietary deficit or erythropoetic issue of the bone marrow can result in a low red blood cell count – called anaemia. A transfusion of whole blood or packed red blood cells may be needed to treat acute blood loss or anaemia. White blood cells White Blood Cells help fight infection, bacteria and other substances that enter the body. When the white blood cell count becomes too low, it is called Neutropenia. G-CSF injections may be needed to treat Neutropenia. Platelets Platelets help blood to clot. Platelet transfusions are given when the platelet count is below normal. Complications of IV Therapy

• Local complications at the site including Extravasation Phlebitis/Thrombophlebitis Haematoma Infection • Fluid overload – Acute Pulmonary Oedema (APO) • Electrolyte imbalance – Cardiac arrhythmias • Transfusion reactions – Anaphylaxis • Air embolus Electrolytes

Electrolytes are minerals in body fluids that carry an electric charge Electrolytes affect the amount of water, the acidity of blood (pH), muscle function, and other important processes in the body There are six major electrolytes • Sodium – Na+ Major cation in extracellular fluid (ECF) • Potassium – K+ Major cation in intracellular fluid (ICF) • Calcium – Ca++ Major cation found in ECF and teeth and bones • Chloride – Cl- Major anion found in ECF

3− • Phosphate – PO4 Major anion found in ICF • Magnesium – Mg++ Major cation found in ICF (closely related to ++ Ca and PO4) Sodium (Na+) Normal Serum Level 135-145 mmol/L

Function • Maintains extracellular function (ECF) osmolarity • Influences water distribution • Affects concentration, excretion and absorption of potassium and chloride • Helps regulate acid-base balance • Aids nerve and muscle fibre impulse transmission Sodium signs and symptoms of imbalance

Hyponatraemia Hypernatraemia • Fatigue • Thirst • Muscle weakness • Fever • Muscle twitching • Flushed skin • Decreased skin turgor • Oliguria • Headache • Disorientation • Tremor • Dry sticky membranes • Seizures • Coma

Potassium (K+) Normal Serum Level 3.5 – 5.0 mmol/L

Function • Maintains cell electro-neutrality • Maintains cell osmolarity • Assists in conduction of nerve impulses • Directly affects cardiac muscle contraction (re- polarisation in the action potential) • Plays a major role in acid-base balance • Sodium – Potassium gradient plays a major role in fluid balance between extracellular (ECF) and intracellular (ICF) compartments Potassium signs and symptoms of imbalance Hypokalaemia Hyperkalaemia • Decreased peristalsis, • Muscle weakness skeletal muscle and cardiac • Nausea muscle function • Diarrhoea • Muscle weakness or • Oliguria irritability/cramps • Paraesthesia (altered • Decreased reflexes sensation) of the face, • Fatigue tongue, hands and feet • Rapid, weak irregular pulse • Cardiac arrhythmias/ • Cardiac arrhythmias/cardiac cardiac arrest arrest Note: Potassium is a heavy • Decreased blood pressure solute that needs to disperse • Decreased bowel motility thoroughly in IV fluid - care • Paralytic ileus should be taken when administering to avoid fatal consequences Calcium (Ca++) Normal Serum Level 2.15-2.55 mmol/L

Function • Enhances bone strength and durability • Helps maintain cell-membrane structure, function and permeability • Affects activation, excitation and contraction of sino-atrial node (intrinsic cardiac pacemaker), cardiac and skeletal muscles • Participates in neurotransmitter release at synapses • Helps activate specific steps in blood coagulation • Activates serum complement in immune system function Calcium signs and symptoms of imbalance

Hypocalcaemia Hypercalcaemia • Muscle tremor • Lethargy • Muscle cramps • Fatigue • Tetany • Depression • Tonic-clonic seizures • Confusion • Parasthesia • Headache • Bleeding • Muscle flaccidity • Arrhythmias • Nausea, vomiting • Hypotension • Anorexia • Numbness or tingling in fingers, • Constipation toes and around the mouth • Hypertension • Polyuria • Cardiac arrhythmias and ECG changes (shortened QT interval and widened T wave Chloride (Cl-) Normal Serum Level 95-110 mmol/L

Function

• Maintains serum osmolarity • Combines with major cations to create important compounds, such as sodium chloride (NaCl), hydrochloride (HCl), potassium chloride KCl) and

calcium chloride (CaCl2) which contribute to acid/base and/or electrolyte balance Chloride signs and symptoms of imbalance

Hypochloraemia Hyperchloraemia • Increased muscle • Headache, difficulty excitability concentrating • Tetany • Drowsiness, stupor • Decreased respirations • Rapid, deep breathing (hypercapnia) • Muscle weakness Phosphate (PO4) Normal Serum Level 0.8-1.5 mmol/L

• Function • Helps maintain bones and teeth • Helps maintain cell integrity • Plays a major role in acid-base balance (as a urinary buffer) • Promotes energy transfer to cells • Plays essential role in muscle, red blood cell and neurological function

Phosphate signs and symptoms of imbalance

Hypophosphataemia Hyperphosphataemia • Parasthesia (circumoral and • Renal failure peripheral) • Vague neuro-excitability to • Lethargy tetany and seizures • Speech defects (such as • Arrhythmias and muscle stuttering) twitching with sudden rise in phosphate (PO ) level • Muscle pain and tenderness 4 Magnesium (Mg++) Normal Serum Level 0.70-1.05 mol/L

Function • Activates intracellular enzymes; active in carbohydrate and protein metabolism • Acts on myo-neural vasodilation • Facilitates Na+ and K+ movement across all membranes • Influences Ca++ levels Magnesium signs and symptoms of imbalance

Hypomagnesaemia Hypermagnesaemia • Dizziness • Drowsiness • Confusion • Lethargy • Seizures • Coma • Tremor • Arrhythmias • Leg and foot cramps • Hypotension • Hyperirritability • Vague neuromuscular changes (such • Arrhythmias as tremor) • Vasomotor changes • Vague GI symptoms (such as nausea) • Anorexia • Peripheral vasodilation • Nausea • Facial flushing • Sense of warmth • Slow, weak pulse References

• Fast Bleep. Medical notes – Fluid Management. http://www.fastbleep.com/medical-notes/other/15/31/205

• Huether, S. E., 2012. Fluids and Electrolytes, Acids and Bases. In Huether, S.E. and McCance, K.L. Understanding Pathophysiology, (5th Ed.). Mosby. St. Louis. pp. 105-126.

• Joanna Briggs Institute. 2008. Management of Peripheral Intravenous Devices. Best Practice. 12:(5), pp.1-4.

• I.V. Therapy made Incredibly Easy! 2010. (4th Ed.). Wolters Kluwer/Lippincott Williams & Wilkins. Philadelphia.

• Macklin, D. and Chernecky, C. 2004. Real World Nursing Survival Guide: IV Therapy. Saunders. St. Louis.